“It could happen to any of us: ” An analysis of access to health care for undocumented migrants in the Netherlands

“We are very sorry our brother Sean-Paul died. It could happen to any of us.’’

This is one of the first notes one would encounter at the entrance of the Refugee Church/Flat when entering on June 19, 2013. Sean-Paul is described as a kind and calm person. He is a former inhabitant of the Refugee Church/Flat and had been recently relocated to housing for mentally ill undocumented refugees that was operated by a local non-profit organization. In this housing unit, undocumented refugees with mental disorders are treated while concurrently being helped with the asylum seeking process.

It is unclear what exactly caused Sean-Paul’s death—a suicide due to his mental illness is one of the likely scenarios. In the weeks before his death, Sean-Paul worried significantly about his uncertain future and complained of fatigue and stress. The funeral, organized by the inhabitants of the Refugee Church/Flat, along with the local mosque, served to remind everyone that their future as irregular migrants is uncertain. What happened to Sean-Paul was not an outlandish event. It could have occurred to any other undocumented migrant.

The ongoing poor social circumstances of undocumented refugees in the Netherlands have compelled some researchers to research alternative access to medical care for the undocumented migrants. [1] A General Practitioner or hospital has at some time turned away one in three undocumented people in the Netherlands. More than half of refugees and migrants do not seek treatment when they need it.

The right to health care is recognized by the UN international covenant on Economic, Social and Cultural rights. [2] States are under the obligation to provide equal access to preventive, curative, and palliative health services for all persons, including undocumented immigrants. [3] In 2005, there were an estimated 75000-185000 undocumented immigrants in the Netherlands. [4] This population constitutes one of the most excluded and vulnerable social groups in our society. They suffer from poor housing and working conditions, isolation, and poverty. Furthermore, they may have experienced difficult circumstances in their respective country of origin—war, violence, famine, poverty, natural disasters, or human rights violations.

In the Netherlands, undocumented migrants are legally guaranteed access to medical care. However, whether or not these undocumented migrants are able to claim this right in the practical sense is disputable. Currently, there is very limited information on the topic of a potential disparity between a legally ordained right to medical care and the actual experiences of undocumented migrants. Through this report, we aim to explore the circumstances that may contribute to this potential disparity through an initial historical contextualization of governmental policy, a close look at current community engagement with this issue through in-depth interviews, and a final assessment of what medical providers can potentially do to directly address this disparity.

Historical Context

The roots of Dutch refugee policy can be traced back to the UN Convention relating to the status of Refugees (1951). “Inspired” by the large flows of forced migrants during the Second World War, the recently formed United Nations considered protecting this vulnerable group a top priority. The Convention clearly specifies which group of migrants deserves special protection. Those who flee their country in threat of persecution (interpreted in a broad way) are officially considered 'refugees' by international law. People who move for other reasons are, according to the UN, “migrants’ who fall under a totally different regime and do not require special treatment. [5] Furthermore, a refugee status is not permanent. Once the situation in the country of origin changes positively, former refugees legally transform into normal migrants and could be treated as such by their host countries.

Aside from international regulations, Dutch policy is also highly influenced by the stance of the European Union. The Member States of the EU became increasingly concerned with border protection after the formation of the Single European Market (1986) and the implementation of the Schengen Treaty (1995), which abolished the internal borders in the EU-area. EU-citizens can now freely cross the borders to other EU-countries without showing their passports. Politicians saw the economic advantages of this development, but were also wary of the risks. Especially if EU border countries, such as Spain, Italy and Greece, would pursue a migration policy that was too liberal, the richer ' inner' countries like the Netherlands and Germany might have to deal with an uncontrollable influx of immigrants. These fears and the massive refugee flow as a result of the Balkan wars in the 1990' s (Germany had to accommodate 80% of all the refugees that entered EU-territory), and the terrorist attacks of 9/11, London and Madrid, resulted in a series of restrictive measures. The EU organized via Frontex (founded in 2005) extensive border patrols alongside the European coast, restricted the freedom of movement for new immigrants and implemented the Dublin Convention.

The Dublin Convention states that refugees need to apply for asylum in the first EU country they pass through. This means that if a refugee travels to the Netherlands via Spain, the Dutch government can send him/her back to the Spanish. Furthermore, each refugee only gets one opportunity— if an applicant fails in one country, he/she does not have to right to try it in another EU member state. Migration scholars coined this development the 'securitization of migration.' [6] European national governments see migration almost exclusively as a threat that needs to be dealt with via repressive means and have lost faith in the positive influences immigration could bring. Ultimately, recent Dutch migration policy cannot be understood without knowing these two (international and European) frameworks. After the Second World War, many Dutch people migrated to Australia and the U.S. The situation became so desperate that Prime Minister Drees was compelled to launch a campaign to give the Dutch an incentive to stay in the country.

However, from the 1960's onwards, the Netherlands attracted migrants from various locations. The Dutch welcomed Moluccans (who were always loyal to the Dutch during the colonial period of Indonesia), guest workers (first from Spain and Italy, later from Morocco and Turkey), Surinamese, Antilleans and refugees from the Balkans. These groups were all at the heart of some social tension when they arrived (the Moluccan train heist in the 1970' s being an obvious example). Yet, the situation did not escalate to such a degree that a general anti-immigration attitude pervaded the Dutch population. This changed in the 1990's. Both politicians and Dutch citizens increasingly experienced the downsides of having to live alongside people who had different cultural norms, or who were seen to be competing for the same scarce resources, such as jobs or housing. Paul Scheffer, a member of the Labour party, published an article in 2000 entitled, 'The Multicultural Drama'. Meanwhile Pim Fortuyn publicly vocalized the doubts many people had about immigration and at this moment, the PVV of Geert Wilders emerged as a force to be reckoned with in the Parliament.

The Dutch policy discourse has shifted dramatically from tolerance to (c)overt hostility with respect to new immigrants in the Netherlands. In 2001, the government implemented a new 'Alien law’, which transformed the Netherlands into one of the most restrictive migration countries in Europe. This law still lies at the heart of the Dutch migration policy. Subsequent governments made migration controls more and more strict. Civil servants were tasked to find out whether asylum-seekers were really 'genuine' and were not ' bogus-refugees' or ' fortune-seekers' In other words, not 'labor migrants in disguise'. If it is possible, the Dublin Convention is applied and refugees are sent back to another European country. Finally, it seems that the authority of declaring home-countries 'safe' lies in the hands of the minister of migration affairs. Different ministers declared countries like Somalia and Iraq 'safe', thus stripping asylum seekers from their refugee status and compelling them to return to their respective countries of origin.

This restrictive policy helped create a significant group of undocumented migrants. Even though the philosophy of the government is that through strict border controls the Netherlands should be an unattractive option for immigrants, it seems that the policy is not very effective. Many migration scholars have [7,8,9,10,11] already studied the effects of harsh border controls and all came to the same conclusion—the 'positive' effects are minimal and the negative effects are potentially disastrous. Among other things, these scholars claim that strict border controls lead to inhumane living conditions and the establishment of an illegal underclass, which might have no other option but to become entrapped into criminality merely to stay alive.

The groups we met during our research and the official fellowship program, be it undocumented migrants in the Bijlmer (Amsterdam South-East), or the residents in the refugee church or the irregulars that meet in the World House, would probably follow this path were it not for the help of local communities. We will discuss their role later on in the report. This section will continue with a short description of how the local municipality of Amsterdam is dealing with the situation in the refugee Church/Flat, serving as a case study of how government officials navigate throughout the tight regulations that are decided at a higher level.

Undocumented migrants have few rights. Their children can go to school until they are 16, they have access to a lawyer and they have access to medical care. The CVZ (College voor Zorgverzekeraars, the umbrella organization of healthcare insurance companies), has a special fund doctors can draw upon when one of their patients is not insured, meaning that there are few financial risks involved when treating the undocumented. Yet, except for providing these bare minimum rights, there is no official government policy on healthcare for undocumented.

In general, government support is limited in regards to the three aforementioned rights. Officially, the local municipality is not allowed to facilitate undocumented migrants in any way. These migrants have no right to food and shelter; hence, providing either good would be a violation of national policy. However, upon examination of the history of the refugee flat/church, it appears that savvy local politicians can still exert some agency, granted amidst a highly restrictive national law, with respect to alleviating the plight of undocumented migrants.

The undocumented that are now gathered in the refugee flat first came together at a tent camp in an Amsterdam district called Osdorp. After a few months, the mayor of Amsterdam ordered the camp to be broken down, since he feared for the health of the refugees. [12] The mayor offered the undocumented migrants places to live that were dispersed all across the city. They refused, as they strongly felt that by sticking together, they could serve as a symbol of failed Dutch refugee policy. The Amsterdam squatting movement spotted a vacant church in the vicinity, squatted it, and allowed the refugees to move together in the church. There they stayed for a few months, until the mayor ordered them to move out, again for alleged security reasons. The refugees, still not prepared to give up the fight for their rights, decided to stick together once again and moved to a vacant office building once again with help from the squatting movement. That is where they are currently residing at the time this report was written.

The role of the municipality in this brief history is quite interesting. Essentially, it chose to espouse a laissez-faire approach—it gave the undocumented immigrants as much room as possible with respect to acquiring basic resources such as food and shelter, despite its official government policy to arrest them and put them in detention centers. One of the reasons why the municipality acted in such a manner is due to the organization of the Dutch state. The Netherlands is a so-called decentralized unity state, which means that although national decision making is essential (national policies need to be adopted more strictly than for example in a federal state), local provinces and municipalities still have a fair share of autonomy. It is difficult for the national government to concretely order the mayor of Amsterdam to arrest the undocumented, since he has almost supreme authority over issues of security in his municipality. The local districts within Amsterdam keep close contact with the people in the refugee church, but cannot officially facilitate them. What they can do, however, is to inform undocumented migrants about their rights to the best of their ability, such as the right to medical care.

In the future, the mayor of Amsterdam wants to form a think tank consisting ofthel people who were involved with the church to find a sustainable solution for the undocumented. This again fits within the policy of municipality: encouraging private initiatives to help the refugees, using its limited capacity to its fullest, but not violating the Dutch national law. The municipality can probably not do much more than that.

Community Engagement

In response to the government's current policy regarding the brutal treatment of irregular migrants, local community-based organizations have emerged as a means of alleviating the poor social standing of this migrant population to the best of their ability. One facet of such community engagement entails increasing access to health care services for irregular migrants. Although legally all migrants, regardless of documentation status, are guaranteed medical care by the Dutch government, the reality of how such care manifests in a highly limited manner for the undocumented has compelled some community-based organizations to focus on addressing barriers to health care among irregular migrants.

Doctors of the World, for instance, has its Netherlands chapter placing an emphasis on improving access to health care for undocumented migrants. [13] This NGO was initially founded in France on March 1980 by a group of fifteen doctors, including Bernard Kouchner who had previously helped establish Doctors Without Borders in 1971. [14] In Amsterdam, Doctors of the World largely serves as a medical referral agency for undocumented migrants.

According to Myrthe van Midde, Coordinator for Migrant Health Care of the Amsterdam branch of Doctors of the World, undocumented migrants often have difficulties with accessing medical care as they are required to show paperwork they do not have or are expected to pay for the services. Although the organization has medical providers, doctors and nurses, who provide weekly medical consultations to migrants, these providers are largely there to listen to patient narratives rather than prescribing medication. If deemed necessary, the organization refers patients to hospitals or other doctors instead.

The rationale for this system, in Myrthe's viewpoint, is that migrants should be accessing health care like any normal person. The underlying assumption is that formulating a hub for medical services that specifically caters to the undocumented migrant population would in fact be perpetuating a problematic system that entails two different standards of care. One for people with proper documentation and one for people without. Such a double standard of care has been documented in many European countries as described by Biswas et al. in their paper entitled Access to healthcare and alternative health-seeking strategies among undocumented migrants in Denmark, The authors argue, "in many European countries there are parallel healthcare systems where NGOs and informal networks of healthcare professionals have taken over the role of the public healthcare system in providing care for undocumented migrants. However, parallel systems may give rise to concern as they seldom have the same facilities as regular hospitals, which may result in difficulties in providing an appropriate quality of care. Moreover, the establishment of parallel systems may risk legitimizing the lack of action on the part of the welfare state." [15] Consequently, Doctors of the World in the Netherlands has attempted to develop a network of GPs to which they can refer the migrants they care for.

Unfortunately, though, this network is currently very limited in its scope. The restricted nature of the network's capacity to address barriers to health care stems from a variety of factors. One factor is the resistance of some GPs to treating undocumented migrants. Although the personal motivation for each individual GP inevitably cannot be conclusively determined, we suspect that this resistance could be partially attributed to a fear of being rendered complicit in illegal activity by providing services to people who fail to show proper documentation.

A second related factor explaining the underdevelopment of the network of GPs entails a dearth of accurate information among health care providers. According to Biswas et al., "the lack of guidelines within the healthcare system may give rise to insecurities about how health care professionals should respond to undocumented migrants." [15] Myrthe from Doctors of the World had confirmed the existence of a similar epistemological landscape in the Netherlands. GPs may be concerned about not receiving appropriate compensation for their medical services to undocumented patients. However, this concern could largely result from a lack of awareness of special government funds that could be utilized to provide such compensation. This particular factor will be explored in greater depth in the report's section on medical providers.

The reality is that even if physicians are aware about the avenues of acquiring compensation for their services to undocumented migrants, the actual value is often inadequate. In response, Myrthe points out how some of the GP's her organization works with have established some clever, and crucial, techniques for ensuring that their efforts in serving undocumented migrants constitute as a financially sustainable endeavor. One such strategy includes the practice of "double consultations." Despite such efforts, there continues to be only a small number of doctors who are consistently working with undocumented patients. These doctors become overburdened with patients and ultimately, according to Myrthe, "a very small portion of the migrant patient population is being served at the moment." One way to alleviate this issue, in Myrthe's opinion, would be compelling the government to reinstate the overseeing group of regional organizations it had in place about ten years ago that tracked all migrants’ access to medical care. The presence of these organizations enabled community based groups to track not only the number of irregular migrants who are accessing medical care in some form but, more importantly, to also assess the portion of irregular migrants who were being denied access.

Myrthe went on to stress that psychosocial factors, such as lack of food or shelter, would inevitably exacerbate the state of any illness. The Refugee Church/Flat serves as one community organization that strives to ameliorate the potential adverse impact of psychosocial factors Thomas is a member of the leading committee that represents Sudanese residents. Approximately two hundred people are currently living in the flat and they are largely grouped according to their nationality (i.e. there are separate rooms for the Eritreans, the Ethiopians, etc.). These residents are provided shelter, but struggle with attaining regular supplies of food. The migrants in the Refugee Church/Flat suffer from a lack of cooking and shower facilities and due to the lack of an ability to work or engage in recreational activities that require funds, one of the biggest enemies of these residents is boredom. According to Thomas, "residents usually sleep in until 1 pm just to kill time and are afraid to leave to the building." [16]

Although medical providers from Doctors of the World provide medical consultations at the Refugee Church/Flat, the migrants are actually still expected to pay for the services - albeit on a "voluntary" basis. However, as evident by the poor living conditions of the migrants in the Refugee Church/Flat, Myrthe's perception regarding the adverse impact of psychosocial factors of health on migrant health is made glaringly obvious. If individuals are struggling merely to have sufficient nutrients in their diet and maintain basic hygiene through showers, let alone are experiencing mentally suffocating circumstances, their health is inevitably going to suffer regardless of the minimal provision of medical services.

Doctors of the World in Amsterdam also works with the community organization called WorldHouse, which shares its mission to work with vulnerable migrant populations of the Netherlands along with the physical building itself. [17] The organization provides an array of services to migrants, ranging from computer courses and trainings on basic rights to facilitation of cultural events. Despite not having a pragmatic value in the conventional sense, it may in fact be the cultural events and other spaces for community formation that constitute as the more important facets of the organization. Research from the UK emphasizes the importance of social relations for the mental and physical health of refugees. Factors such as having an active social network and being able to speak the English language to communicate with the population positively contribute to both the emotional (mental) and physical health of the asylum seekers [18].

Myrthe's experiences through Doctors of the World buttress the posited direct relationship between access to social capital and health care services. Myrthe recounted how immigrant communities that already have structured social cohesion internally are easier to reach. For instance, African migrant populations are more accessible through institutions such as churches. Yet, the Chinese migrant populations on the other hand, are more difficult to reach due a lack of analogous binding social institutions. Currently, Doctors of the World is striving to increase outreach to Muslim migrant populations by developing trust and connections with local mosques.

The current role of healthcare providers

As mentioned earlier, there is a special fund for health care professionals to cover the costs of the treatment of the uninsured. General Practitioners, midwives, and pharmacists could obtain a 100% reimbursement. Hospitals and mental care institutions were initially obliged to cover unmet costs out of their own resources. Today, reimbursement for general practice is available for up to 80% of the costs. However, not all healthcare providers are aware of the existence of this fund and some of them refuse treatment of undocumented immigrant because of this reason. On the other hand, undocumented refugees themselves are not informed about this possibility and may, therefore, not go to visit a doctor.

Dr. Majda Lamkaddem, who has recently completed her dissertation entitled, “Health and healthcare utilization of ethnic minorities in the Netherlands”, concluded that the incidence of post traumatic stress disorder (PTSD) among migrants is double compared to the incidence in the native population (15% compared to 7%) [19].Health improvements were not influenced by the attainment of a residence permit but, rather, by the subsequent improvement of the experienced living conditions, in particular employment and the presence of family and social support. Despite these health improvements over time, Dr. Lamkaddem’s research has shown that the prevalence of PTSD remains high, even several years after resettlement.

According to Dr. Lamkaddem, “accessibility to health care includes financial accessibility, cultural accessibility, cognitive/informational accessibility, and language accessibility. ”[20] At the moment, immigrants in general often perceive a cultural distance with the doctors (i.e. cultural insensitivity). Migrants often go to a specialist in their respective countries of origin, which hinders the continuity of medical treatment. Majda argues that the Dutch healthcare system should take cultural differences into account, such as variations in the role and expectations of a doctor in other cultures. Furthermore, the current lack of government subsidies for medical translators is particularly detrimental for migrants. Majda asserts that there is no true alternative to formal medical interpretation services. Family members who informally serve as translators inadvertently can interject family dynamics and other problems into the clinical care. Bilingual providers, however, may somewhat alleviate the problem.

A group of committed physicians have voluntarily set up a doctors clinic at the refugee church/flat and come daily to the refugee flat to check upon the ill and treat them when possible. The vast majority of the patients they treat here have signs of post-traumatic stress disorders, depression, and even psychoses. In many cases, the physical complaints come as a result of mental health deterioration. Doctor van Langeraar, a young first aid physician in Amsterdam, volunteers twice a week to treat the patients in this flat. She walks by the different rooms in this flat and inquires about anyone who may be seeking medical help. Nowadays, there is not much to do for her since she and her colleagues have managed to relocate many of the chronically diseased and those who need more specialized treatment to other houses or institutions. For example, all of the pregnant women have received assistance with securing normal housing.

Currently, the vast majority of complaints of the patients she meets in the refugee church/flat are associated with depression, post-traumatic stress disorder, and other mental diseases. Doctor van Langeraar is particularly worried about the prevalence of circadian rhythm disorders among the undocumented. The refugees usually do not sleep before late midnight and do not wake up until late afternoon. A perceived lack of any purpose in life and fatiguing boredom, in conjunction with anxiety over an uncertain future, leads to physical and mental complaints that are not easily resolved as long as their circumstances remain the same.

Another important task for these physicians is to inform refugees about the Dutch medical care system along with educating local health care providers, such as hospitals and general practitioners, about the possibilities of treating these immigrants even though they are uninsured. Over the last few months, these physicians have been able to assign most of the inhabitants of the refugee church/flat to a local GP and inform the local pharmacies about the existence of this vulnerable group as a means of formulating agreements on how to best help them.

According to Doctor van Langeraar, it is not important whether or not these migrants are entitled to stay legally in the Netherlands. For a doctor, treatment of diseases comes first. Thus, these people should receive treatment when needed like any other human being. [21]

Discussion and recommendations

In this report, we discussed the accessibility of healthcare for undocumented migrants in the Netherlands. We analyzed the problem in its political-historical context, mapped how local communities endeavor to help the undocumented, and, finally, described the possible role of the healthcare service providers. These three sections granted us different but equally valuable insights. First of all, the policy context, ranging from the international to the local level, is clearly one of the roots of the problem. The current policy framework leaves room for national governments to declare significant parts of the immigrant population ' illegal.' Obviously, the problems that we discussed relate to this simple fact. Being illegal limits the options of migrants to use facilities the national government has to offer (be it de jure or de facto) and this perpetuates their already vulnerable situation. The history of the Refugee Church/Flat shows that local municipalities have some agency to deviate from the repressive national framework. However, if we strive for a long-term sustainable solution, it is evident that we need to fundamentally rethink our conception of immigration and illegality, both at the national and international level.

The sections on local communities and healthcare providers showed us that good willing people are capable of many things but, also, that their constitution and agency is limited. The Refugee Church/Flat is losing volunteers day by day. Doctors of the World could probably continue their work for quite a while but their manpower is lacking, The Worldhouse is a nice meeting place for migrants but can naturally only give refuge to a limited number of undocumented. The biggest feat of the local communities, alongside providing essentials such as food, might be that they help the undocumented actually claim the few rights they have. Many undocumented are, for example, unaware of the fact that they can get medical care. The same goes for the doctors: they usually do not know that they can, for instance, actually get paid when they are treating someone who is undocumented and has no insurance. Organizations like Doctors of the World can mediate between these two groups and reduce the gap between 'de jure' and ' de facto.'

Still, in a modern democracy we should probably also look beyond the concrete political or local community perspective. The way the general population looks at undocumented is crucial in a democratic system. At the moment, many people continue to be in favor of restrictive migration policies and support government plans to make illegality punishable by law. This general stance directly affects the mental health of the refugees. One of the reasons that migrants develop emotional issues is due to the fear of not being allowed to stay in the country.

Such a viewpoint also makes it virtually impossible to achieve any change at the political level. It limits the potential circle of local community members that are willing to help undocumented immigrants stay alive. Practical solutions are naturally always useful but will ultimately only address the symptoms and not the roots of the problem. Perhaps the best way to help undocumented migrants is to think about how we can change the way everyone, not just the policy makers, thinks about immigration. Reconsidering whether it is even appropriate to call someone 'illegal' may open a new perspective for change. For now, we need to keep faith in the power of local communities and the lenient attitude of municipalities.